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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> MailingAddress: 3� ���]? <br /> ���0 PO Box 66 Permit number: <br /> Crystal Bay, MN 55323-0066 Date received: -(p " <br /> StreetAddress:' Received by: � <br /> y ,� 2750 Kelley Parkway Plan review fee: <br /> F c,` Orono, MN 55356 <br /> `�kEgHO�� Main: 952-259-4600 Total Fee: �j�'l.�� <br /> FaX: 952-249-4616 w',�ivt ci orcnn mr �.is l <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: � � � � •�` �� � <br /> Job Site Address: �3U 5 u.. �.� r�,,�'t— 7 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> If yes, a special evenf permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/�j PLICANT IN ORMATION: <br /> Name: ( =��rc.� �e7f'N�e,- — Q�.r����� <br /> State License# —� Expiration Date: <br /> Phone: cell l L��- ��•% �U office <br /> Mailing Address: �j •9,� r�;ri � Cit :. ��•.— � �-`�.S�� <br /> Contact Person: � ��� or� �� Applicant is: Contract r / m f (Circle One) <br /> Email and/or Fax: � � c -or� �{L, � �-.,� �.�� <br /> PROPERTY OWNE NFORMATIO <br /> Name: �i,e;�y� >►�yr-.�:.� <br /> Phone (day): ,Z .� �, <br /> Address: �v'��s(��.�,�, n�:�J� �xe,,� City���2,�,�',� ZIP: y�.3`P / <br /> Email and/or Fax �j �� J , ��r �r,•rL • 1, � � <br /> ARCHITECT/ ENGINEER INFORMATI <br /> Name: ,Da..✓;`� iG�- <br /> Phone (day): " L• ,5 3� , '�y <br /> Address: ,� ,� rc(,� Cit � �(J .c:�' ZIP: '�� <br /> Email and/or Fax: ce�i7 � - i �.�" � �t, � e <br /> PROJECT INFORMATION: Description of project: <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal & <br /> Water Supply <br /> ❑ New Construction Single Family with �f�esidence <br /> [�A�ddition attached garage �'Garage/Accessory Bldg. �Public Sewer <br /> ❑ Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial ❑ Private Sewer <br /> ❑ Other: (specify) ❑ Multiple Family/Condo ❑Warehouse <br /> ❑ Public ❑ Storage Public Water <br /> **Any earth movement may require ❑ Commercial ❑ Other(specify) <br /> MCWD review&permits. ❑ Industrial ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (speCify) <br /> 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ �2'�'`� <br /> Packet Last Updated: 04/19/2013 <br /> Page 22 of 23 <br />